Microsoft word - medicationpermissionform.doc

Girl Scouts Louisiana East
Corporate Headquarters
Regional Service Center
841 S. Clearview Parkway, New Orleans, LA 70121-3119 545 Colonial Drive, Baton Rouge, LA 70806 (504) 733-8220 (800) 644-7571 F (504) 733-8219 (225) 927-8946 (800) 644-7571 F (225) 927-8402 Medication Administration Permission Form
Place this form inside zip lock bag with your Girl Scouts’ medications
Name_______________________________________________________________________________________________________ Parent/Guardian Name_________________________________________________________________________________________
Phone (H) (________)_____________________ (W) (________)____________________ (C) (_________)_____________________
All medications and this form are to be given to Adult in Charge of event – Leader, Co-Leader or First Aider upon arrival
Please do not pack medications in your Girl Scouts’ suitcase. All medications must be administered under direction of the Adult in
Charge. This includes all over the counter medications such as aspirin, Tylenol, ointments and vitamins, AND prescription drugs. If your
child is taking medications to the activity they must be clearly marked with her name and the name of the medication listed on this
form. Review with Adult in Charge upon arrival. All medications must be sent in the original container. * Most over the counter
medication (aspirin, Tylenol, Benadryl, etc.) will be on hand .
Medication____________________________________ Medication____________________________________ Taken for_____________________________________ Taken for_____________________________________ Dosage (amount)_______________________________ Dosage (amount)_______________________________ How often_________________________________ How often_________________________________ Give regularly?_____________________________ OR Give regularly?_____________________________ OR Only when needed?__________________________ Only when needed?__________________________ Medication____________________________________ Medication____________________________________ Taken for_____________________________________ Taken for_____________________________________ Dosage (amount)_______________________________ Dosage (amount)_______________________________ How often_________________________________ How often_________________________________ Give regularly?_____________________________ OR Give regularly?_____________________________ OR Only when needed?__________________________ Only when needed?__________________________ Medication Administration Permission Form (continued) Medication____________________________________ Medication____________________________________ Taken for_____________________________________ Taken for_____________________________________ Dosage (amount)_______________________________ Dosage (amount)_______________________________ How often_________________________________ How often_________________________________ Give regularly?_____________________________ OR Give regularly?_____________________________ OR Only when needed?__________________________ Only when needed?__________________________ Please Attach Additional Sheets for Additional Medications
If severe allergic reaction occurs – is epi pin necessary?  Yes  No If yes, epi pin must be included with medications.  Girl Scout has permission to self-administer inhaler as needed and is responsible for its use.  Girl Scout has Epi-pen and has permission to self -administer as needed and is responsible for its use.  Girl Scout requires assistance from personnel specifically trained to perform procedure (such as giving injections, testing blood sugar, etc.) Specify: _____________________________________________________________________________  Girl Scout is bringing the following medical equipment to camp: ________________________________________________ ___________________________________________________________________________________________________  Girl Scout has permission to receive over the counter medications such as aspirin, Tylenol, Benadryl, etc.

Special comments / instructions (if necessary):


The medications indicated above are to be administered to my Girl Scout while at the activity.
Parent/Guardian_____________________________________ / ______________________________________ Date _____________

Source: http://www.gsle.org/blog/wp-content/uploads/2013/10/FRM-MedicationPermission.pdf